GW1-2022-03297_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Internal use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Gary Ellingworth 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 42 fL 51 ft. i Wet
3367 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc.
Compam Name 16,INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit 4: 0 ft. 11 ft. 4 in. SCh40 PVC
List all applicable well permits(i.e.Counrn.Slate,Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 11 fL 51 ft. 4 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rr. 36 ft- Portland Cem Tremie
Non-Water Supply Well:
0 Monitoring ❑Recoven
36 ft• 38 ft• Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
38 f` 51 ft• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well 1-20-22 s)Completed: Well ID# RW-108
5a.Well Location:
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
14511 Huntersville-Concord Road, Huntersville, NC 28078 a ft.
Physical Address,City,and Zip
21.REMARKS MAR 14 _
Mecklenburg No Cover.,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:(ifwell field,one lat/long is sufficient)
35.414571 N -80.806509
SignatJeoCertified Well Co tractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 8v,sigti.s fiirnr,I hereby cerlifi,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCA'62C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oj'this record has been provided to the well owner.
/(this is a repair,fill out known well construction information and explain the nature of?he
repair under=21 remarks section or on the back at this orin. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessan,.
For multiple injection or non-waler supply wells ON1.Y with the same construction.You can
submit one firm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 51 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@100'and 1 n 100') construction to the following:
10.Static water level below top of casing: 42 Division of Water Resourlces,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6 5/8 HSA , & 2�r SpOOnS 24aabove, also submit a copy of this form wi[hin 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY"WELLS ONLY: 1636 Mail Service Center'
enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013